Skin preparation protocol helped reduce posterior cervical infection

A new protocol has been designed to greatly reduce the rate of postoperative posterior cervical wound infections.

Several steps taken preoperatively, intraoperatively, and postoperatively can radically reduce the rate of postoperative wound infections from posterior cervical surgery, according to study findings.

Brian J. Neuman

“Our perioperative protocol for skin preparation exposure and wound closure has shown a substantial decrease [in], if not eliminated the risk of posterior cervical wound infections. In this study we looked at various cervical procedures, multiple patients with different medical comorbidities, patients of various body habitus, and multiple patients that had thickness of the posterior cervical subcutaneous fat. Despite these risk factors, we had no infections,” Brian J. Neuman, MD, said.

Preparation of the surgical site and plastic drapes with an alcohol foam is shown.

Meticulous hemostasis is obtained with the use of various hemostatic agents. A deep drain is placed in all cases, and patients who clinically have great than a 2 cm layer of subcutaneous fat have a second superficial drain placed.

Images: Neuman B

“This was a follow up to a study by the Cervical Spine Service at Washington University Orthopedics in St. Louis in the Journal of Bone and Joint Surgery in 2013, which demonstrated a vanishingly low rate of infections. That study had reported on the first 195 patients treated with vancomycin powder along with the rest of the protocol. None had infections. The current study was a follow-up with a larger group,” he told Spine Surgery Today.

In particular, the protocol used by the senior author on the Cervical Spine Service, which involves specific preparation of the surgical site and using alcohol foam, was effective regardless of a patient’s comorbidities or body habitus, or the thickness of the posterior cervical subcutaneous fat. Subcutaneous fat thickness was found in some studies to be a significant risk factor for infection, and it was present in half the patients included in the study, Neuman said.

The rate of infection for posterior cervical wounds is reported as high as 18.2%, Neuman said.

Goal: Reduction in infections

In contrast, using a standard protocol for preparation of the skin, exposure and wound closure for posterior cervical spine surgeries, Neuman and his colleagues analyzed the infection rates for 461 such consecutive cases performed between 2008 and 2012 at Washington University Orthopedics by a single surgeon. The cases included decompression with or without instrumentation, instrumented fusions and 15% of them were revision posterior surgeries. Preparation of the surgical site and plastic drapes with an alcohol foam is shown. Meticulous hemostasis is obtained with the use of various hemostatic agents. A deep drain is placed in all cases, and patients who clinically have great than a 2 cm layer of subcutaneous fat have a second superficial drain placed.

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Neuman and colleagues defined an infection as acute if the patient needed reoperation within 30 days and there was evidence of gross pus intraoperatively or there were positive intraoperative cultures.

The protocol begins with the patient shaving the surgical site the night before surgery. Prior to the surgery the surgical site and plastic drapes are treated with an alcohol foam. During exposure, the dissection is down the midline in the avascular plane between the paraspinal musculature, which preserves the interspinous ligament attachment to the muscle and reduces blood loss and muscle necrosis, according to Neuman.

“Prior to closure, meticulous hemostasis is obtained. This is done with various hemostatic agents. A deep drain is placed in all cases, and patients who clinically have greater than a 2-cm layer of subcutaneous fat have a superficial drain placed. Vancomycin powder is placed in all wounds being 0.5 g to 1 g, depending on surgeon’s preference and wound size,” Neuman said.

Multi- step protocol

The surgeon closes the wound in multiple layers.

“We approximate the normal anatomy and eliminate the dead space. This is first done with closing the interspinous ligament with muscle attachment, and then closing two subfascial layers. The closure is then continued to be performed with a multi-layer closure through the fascial and through the subcuticular layer,” he said.

All patients receive perioperative antibiotics. Once the output reaches less than 30 mL in an 8-hour shift the use of drains is discontinued, according to the abstract. This practice led to a 0% rate of acute posterior cervical wound infection rare despite various comorbidities and body habitus in the patients studied.

“One percent of patients underwent a reoperation for postoperative hematoma, however there was no evidence of infection and they had negative intraoperative cultures,” Neuman said in his presentation. – by Robert Linnehan

References:

Neuman BJ. Paper #216. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans.
Pahys JM. J Bone Joint Surg Am. 2013; doi:10.2106/JBJS.K.00756.

For more information:

Brian J. Neuman, MD, can be reached at Johns Hopkins University, 601 Caroline St. JHOC 5241, Baltimore, MD 21287; email: bneuman7@jhmi.edu.

Disclosure: Neuman has no relevant financial disclosures.